Street Paws Spay/Neuter Application

Street Paws Spay/Neuter Application
The spay/neuter assistance is for adult residents of Henry County showing financial hardship which prevents them from spaying/neutering their pets. The funds for this program are limited and only include the cost of spay/neuter, so it is important that we serve those who need our help the most. Note: this pet is not for feral cats.

I understand
Am I eligible to apply? To participate in this program, we require the following: Applicant must be 18 years or older. Only 1 applicant per household. A completed application.

I understand
Your pet must be able to be handled safely by the vet. No feral, fractious, has a potential to bite or dangerous animal(s) can participate in this program. *
To Help Us Help You
In order for Street Paws to continue assisting families in need, we must share stories, photos, and videos with our grant partners. Your story helps us secure the funding that makes this program possible.

Please upload a photo of your pet and include a short statement about how our assistance will make a difference for you and your pet.
These personal stories truly help us show the impact of our work and reach more families in the future.
Upload a photo of your pet*

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Write a short statement about how our assistance will make a difference for you and your pet.*
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Where did you hear about us?*

A friend or colleageGoogleFacebookOther
Information about your pet*
Name of Pet*
Age of Pet*
Weight of Pet*
Breed of Pet*
Color/Description*
Has this pet ever been to the vet?*
If you have a dog, does he/she need any of the following?*

RabiesDA2PPHeartworm TestBordatella (Kennel Cough) VaccinationDewormerMicrochipI don't knowI have a cat
If you have a cat, does he/she need any of the following?*

RabiesFVRCPFIV/FeLV TestFeLV VaccinationDewormerMicrochipI don't knowI have a dog
Amount you can contribute towards the cost of veterinary care?*
Current household income per month from all sources (before taxes)*
Please list any assistance programs from which your household receives help*
Any additional useful information? (In heat, pregnant (how far along), has this pet ever given birth, not friendly, outdoor pet, feral)*
To ensure our resources are directed to those who require them most first, please select if you receive any of the following benefits:

Public HousingSupplemental Security IncomeDisability/SSDMedicaidWelfareTemporary Assistance for Needy Families (TANF)Food Stamps (SNAP)WIC (Women, Infants, and Children)Food and Nutrition ServicesIncome below 200% of the federal poverty level.
Participation Rules and Obligations: I understand my commitment outlined below, and will abide by the following rules and regulations regarding my participation in the spay/neuter assistance program. a.) I understand that Street Paws reserves the right to terminate this agreement in protection of its organizational integrity if I fail to comply. b.) I agree to follow guidelines outlined by the program administrator and the veterinarian performing the spay/neuter surgery. c. I agree to submit proof of residency (drivers license, utility bill, etc) e.) I understand that I am willingly agreeing to pursue veterinary services for my pet(s) listed above, and release Street Paws from all liability resulting from any veterinary services I receive from an independent veterinary clinic. f.) I understand that any additional veterinary services required for my pet(s) are my own financial responsibility, and I release Street Paws from any financial liability resulting from additional veterinary services. g.) I understand that Street Paws assistance is for pets owned by me (the applicant). The information I have provided about myself, my pet, and my household income are accurate and truthful. I certify that the information I have provided on this application is true and that giving any false information will result in the disqualification of this application and any future applications from Street Paws. h.) Fraudulent use of this program will result in services charged to me at full price and possible legal action against me and others involved in fraudulent use of this program.

I have read, understand, and accept the rules and obligations for participation.
Upload copy of your driver's license here*

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Upload copy of your proof of residency here*

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